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HomeMy WebLinkAboutBLDP & G-23-002333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ;NI CITY YARMOUTH MA DATE 10/31/22 PERMIT# BLDP-23-002333 l JOBSITE ADDRESS 32 DAVIS RD OWNERS NAME WOLFGRAM ALVIN G P OWNER ADDRESS P 0 BOX 863 ESSEX,CT 06426-0863 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL E PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURFS z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Stephen Winslow LICENSE 12298 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '� MA DATE 10/23/22 PERMIT# -.gut f= CITY YARMOUTH '7"1 z 3 3 3 JOBSITE ADDRESS 32 DAVIS ROAD OWNER'S NAME ALVIN WOLFGRAM P OWNER ADDRESS SAME TEL 860-304-6558 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL 0 PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES j NOEI FIXTURES 1 FLOOR BSM 1 2 3 j 4 5 6 1 7 8 9 10 11 12 13 1 14 BATHTUB • s DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER Sr., DISPOSER FLOOR iiii liii iiiinniallin LAVATORY 11.0.11111111111111111111111.11MINIIII ROOF DRAIN SHOWER STALL iniiillinallinni mom innwirino am SERVICE/MOP SINK TOILET WININ URINAL WASHING MACHINE CONNECTION NW 1111111111111111111M11. WATER HEATER ALL TYPES 1 WATER PIPING OTHER M INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true r e to the b' t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co Ii wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME[STEPHEN WINSLOW 1LICENSE#[12298 �. SIGNATURE MP El JP® CORPORATIONEJ# 3281C PARTNERSHIP# a LLC0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH j STATE MA ZIP 02664 TEL 508 394 7778 FAX 508-394-8256 j CELL I N/A I EMAIL INSPECTIONS EFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A' CITY YARMOUTH MA DATE October31,2022 PERMIT# BLDP-23-002333 ti a JOBSITE ADDRESS 32 DAVIS RD OWNER'S NAME WOLFGRAM ALVIN G G OWNER ADDRESS P 0 BOX 863 ESSEX CT 06426-0863 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES ❑ NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME (Stephen Winslow LICENSE# 112298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' El CORPORATION 0# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 1026641207 I TEL I FAX I CELL I EMAIL (inspections at7,efwinslow.com I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t i=z CITY YARMOUTH �`2aJ MA DATE 10/23/22 PERMIT# 23— Z 3 3 JOBSITE ADDRESS 32 DAVIS ROAD GOWNER'S NAME ALVIN WOLFGRAM OWNER ADDRESS LSAMEE 1 TE 860 304 6558 FAX � —. TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL CLEARLY NEW:L- RENOVATION:0 REPLACEMENT:LI PLANS SUBMITTED: YES 0 NO L] APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , CONVERSION BURNER i .::: .. : ..... COOK STOVE .... . ' DIRECT VENT HEATERIIMIlit DRYER 11.1011.1111111111111111111.111 FIREPLACE _ ' FRYOLATOR FURNACE , ... ...:. r GENERATOR _ GRILLE INFRARED HEATER NM MiimiluilimiriitiMMOMillilaillimMi, LABORATORY COCKS I MAKEUP AIR UNIT OVEN immimmiliiMillinlimilMOMMOOMMIN .., � POOL HEATER ROOM/SPACE HEATER i ROOF TOP UNITam TEST ,1111111 OM Mr MIMI OMNW UNIT HEATER p6> p UNVENTED ROOM HEATER r WATER HEATER OTHER w _-._ _ w .... v ... 1--- 1111.111110111111.11M1.1111.1411111.0111111101111111011101.1111.1111111.11 NMI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY Li BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cornplianc a P�rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �7�"� PLUMBER-GASFITTER NAME STEPHEN WINSLOW 12 ... .. r "E' LICENSE# 12298 SIGNATURE MP _�_ MGF JP JGF .. LPGI ... a CORPORATION EP 3281CTJ PARTNERSHIP # __.. LLC D# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH — j__ STATE MA ZIP 02664 TEL 508 394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ............ .......... The Commonwealth of Massachusetts Department of Industrial Accidents is-Air X Office of Investigations O,.w Lafayette City Center l. 2 Avenue de Lafayette,Boston,MA 02111-1750 '`-4 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): 1.® I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).*-) 6. LJ RestauraritTBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. [' Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.❑Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yea;imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer • e the ins and penalties of perjury that the information provided above is true and correct. Signature: C ' 1 Date: 12/01/2021 Y�'` Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1IBoard of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia